For more than a quarter century Massachusetts has been
a leader in promoting legal equality for lesbian, gay,
bisexual and transgender (LGBT) people and same-sex
couples. Ten years after it became the first state to legalize
marriage for same-sex couples and 21 years after Governor
William Weld launched the first Governorâ&#x20AC;&#x2122;s Commission on Gay
and Lesbian Youth, Massachusetts continued in this proud
tradition in 2013, when the state legislature and Governor
Deval Patrick joined together to create the first-ever statewide
LGBT Aging Commission to address the unique concerns
and needs of LGBT older adults. From April 2014 through
June 2015 the Massachusetts LGBT Aging Commission held
listening sessions around the Commonwealth, consulted with
elder service providers and experts on LGBT aging, and
developed comprehensive recommendations in a number of
issue and service areas. If 5% of all older adults are LGBT,
then we estimate approximately 65,000 LGBT older adults
are living in the Commonwealth. For a number of reasons
including lower rates of parenting and estrangement from
families of origin, LGBT elders may be more in need of formal
elder services. But because LGBT elders fear that they will
experience discriminatory treatment in elder services, and
often experience discriminatory or culturally incompetent care,
they may be less likely to access those very services.

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LGBT AGING COMMISSION

EXECUTIVE SUMMARY

In this report the Massachusetts LGBT Aging Commission makes
recommendations in five major areas: long term support services, housing,
public health, senior centers and community engagement, and legal
considerations. It also makes recommendations regarding data collection,
needs assessment, cultural competency training and evaluation, outreach
and access, service delivery, complaint resolution, and legislation. Overall
themes include:
•

the importance of collecting data on sexual orientation and gender
identity to quantify, understand, and address any disparities that LGBT
elders experience compared with the majority of elders who are
heterosexual and not transgender;

•

the need for training of elder service staff in the unique experiences and
needs of LGBT elders;

•

the need for nondiscrimination protections, especially protections for
transgender people against discrimination in public accommodations,
which include nursing homes, health centers, public transportation and
retail establishments;

•

the need for outreach and access to ensure that LGBT elders
are accessing services they need and are entitled to, such as
veterans services;

•

the importance of emulating big cities across the U.S. that have created
elder housing communities for LGBT elders and their friends and allies;

•

the need for an LGBT ombudsperson within the Executive Office of
Health and Human Services to ensure the integration of LGBT concerns
into the Commonwealth’s aging and human services networks, and to
advocate for LGBT elders who experience barriers to accessing and
utilizing services as whole human beings;

•

and the need to assist LGBT elders in advance planning for
decision-making during periods of incapacity or end of life.

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LGBT AGING COMMISSION

INTRODUCTION

About the Massachusetts LGBT Aging Commission
The Legislature is to be commended for establishing this first-in-the-nation
statewide Commission to address the unique concerns and needs of older
lesbian, gay, bisexual and transgender (LGBT) individuals. Convened in
April, 2014, the Commission represents the latest milestone in the history
of LGBT equality in the Commonwealth (see “Massachusetts’ Leadership
in LGBT Rights” in Appendix A). It is expected that the results of this
Commission will be of interest not only to Massachusetts legislators and
the people of Massachusetts, but also to many legislators, advocacy
organizations and individuals across the country.

Enabling Legislation
In August, 2013 Governor Deval Patrick signed into law Chapter 38 of
the Acts of 2013, An Act making Fiscal Appropriations for the Fiscal Year
of 2014 for the Maintenance of the Departments, Boards, Commissions,
Institutions and Certain Activities of the Commonwealth. Section 186 of
this Act established a special Commission charged with examining the
impact of state policies and regulations on LGBT older adults and making
recommendations ensuring equality of access to treatment, care and
benefits; increasing provider awareness of the needs of LGBT older adults
and caregivers; enhancing programming and services for LGBT older adults;
examining best practices (in Massachusetts and other states) for improving
quality of life for LGBT seniors; preventing premature admission of LGBT
elders to institutional care; ensuring access to affordable and culturally
appropriate community based care options; developing a plan for statewide
training curricula to improve the delivery of health care, housing and long
term support services to LGBT older adults and caregivers; and considering
outreach protocols to reduce apprehension among LGBT elders and
caregivers. The LGBT Aging Commission is the first statewide Commission
in the country to focus on the needs of LGBT seniors.

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LGBT AGING COMMISSION

INTRODUCTION

Commission Members
Convened by the chairs of the Joint Committee on Elder Affairs, Representative
James O’Day and Senator Patricia Jehlen, the Commission includes the following
members (members 3 to 15 below are designees of their organizations as per the
enabling legislation):
1.

House Chair of Joint Committee on Elder Affairs
Representative James O’Day, Co-Chair of the Commission

2.

Senate Chair of Joint Committee on Elder Affairs

Senator Patricia Jehlen, Co-Chair of the Commission

3.

Executive Office of Elder Affairs (EOEA):

Ken Smith, Director of MassHealth Long Term Services and Supports

4.

Massachusetts Department of Housing and Community Development (DHCD):
Alana Murphy, Director of Policy

The lives of today’s older lesbian, gay, bisexual and transgender (LGBT) people
were molded under conditions of intense homophobia, both during their formative
years, as well as throughout much of their adult lives. Homosexuality was illegal
and subject to imprisonment. The police routinely raided places where LGBT people
gathered and entrapment was an official law enforcement practice. LGBT people
were often targets for blackmail.

•

Before the advent of the modern LGBT civil rights movement, homosexuality was
officially categorized by psychiatry as a mental illness, by medicine as a physical
disorder, by mainstream religious groups as a sin, by both employers and families
as shamefully unacceptable, and by the media as corrupt and perverted.

These repressions often led to extreme marginalization and crippling stigma. Many
LGBT people adapted to this repression by living in a highly invisible manner, in what
is now known as “the closet.” Most pretended to be straight or avoided mainstream
assistance out of fear. Even today, many older LGBT people let only a trusted few in
on the secret of their sexual orientation and/or gender identity.

services such as attending a senior center or congregate meal program, housing
assistance, food stamps, or other entitlements.2 Lower rates of accessing mainstream
senior services can exacerbate social isolation, which is known to contribute to
depression and poor treatment adherence.3 These factors, coupled with the lower rates
of parenting among LGBT elders noted above, make LGBT eldersâ&#x20AC;&#x2122; ability to access
nondiscriminatory and affirming elder services especially important.
Higher rates of poverty in the LGBT community may also make LGBT older adults more
dependent on publically funded elder services. Despite stereotypes of gay people
as economically privileged, national population-level surveys such as the American
Community Survey, National Survey of Family Growth, and Gallup Poll indicate that
LGBT people experience rates of poverty similar to or higher than the rest of the
population.4 Female same-sex couples,5 or lesbian couples, experience higher rates
of poverty than married heterosexual couples. African Americans in same-sex couple
households experience higher poverty rates than African Americans in heterosexual
married couple households or White same-sex couple households.6 Among women
18-44, 29% of bisexual women and 23% of lesbians are poor, compared to 21% of
heterosexual women.7 Among men in the same age group, 26% of bisexual men
and 21% of gay men are poor,8 while only 15% of heterosexual men are poor. Lower
earnings in youth and middle age can translate into higher rates of poverty in older
adulthood. Studies indicate very high rates of poverty among transgender Americans.9
LGBT older adults are more likely to have a disability than older adults in general.10 Half
to two thirds of people living with HIV/AIDS in the U.S. are gay and bisexual men11 and
transgender women.12 About half of the HIV-positive population in the United States is
now age 50 or older.13 Older adults living with HIV are more likely to have comorbidities

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LGBT AGING COMMISSION

than other older adults.14 Four in 10 HIV-infected people receive Medicaid, public
insurance for low-income individuals.15
A growing body of research has documented LGBT health disparities in health and
disease outcomes,16 17 risk behaviors and factors,18 19 rates of insurance coverage, 20 21
access to preventive care,22 23 and access to culturally competent care.24
As a result of all these factors, LGBT older adults have a greater need for the publicly
financed and regulated continuum of care that was developed to address both longer
lifespans and changing caregiving patterns. However, most aging service providers are
not trained in how to provide culturally competent, affirming care to LGBT elders.25
This combination creates a “perfect storm,” which includes greater need for aging
services to help LGBT older adults age in place and stay out of costly institutions,
lack of trust of mainstream services and providers, and potentially underprepared
elder service organizations.
The Commission believes strongly that the disparity in LGBT utilization of publicly-funded
and regulated aging services must be removed from the policy closet. Without policy
and program reforms designed to improve both access and utilization, the growing
cohort of aging LGBT people will continue to eschew accessing elder services.

So any fears (about aging) that heterosexuals may have, you can probably
times it by five at least for LGBT seniors, considering the stigma, the fear,
and the discrimination that they’ve face throughout their lifetime, it’s just so
overwhelming that they’re so afraid that they may have to climb back into the
closet that took them 40 to 50, 60 years to climb out of; it’s just not acceptable.
9

“

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LGBT AGING COMMISSION

INTRODUCTION

Methodology
Starting in April 2014, the Commission met on a regular basis for more than
a year. Commission meetings were open to the public, and were posted on
www.malegislature.gov a week in advance.
At the first meeting, the Commission decided that in order to carry out the
Commission’s mandate, the Commission would need to hear and collect
testimony regarding experiences accessing services directly from the
members of the LGBT community, their caregivers, and their friends.
The Commission convened four public “listening sessions” across the state,
in which members of the public and community groups were asked to attend
and speak to us about the issues and needs LGBT seniors encounter, and
the barriers they face to accessing state and community services. The
listening sessions were held in Orleans, Boston, Worcester, and Holyoke,
in order to learn about any regional variations and needs of the elderly and
aging LGBT population across the Commonwealth’s varied regions (Cape
Cod, Greater Boston, Central Massachusetts, and Western Massachusetts.
All testimony was recorded for record keeping and analysis, unless the
speaker specifically asked not to be recorded.
The Commission also solicited and received written comments separate from
the hearings. Additional commentary was provided at informal gatherings of
LGBT older adults. These options were particularly beneficial for individuals
who wished to maintain their anonymity. The Commission also hosted a
presentation and briefing with Professor Nancy J. Knauer, the I. Herman
Stern Professor of Law and Director of Law & Public Policy Programs at
Temple University’s Beasley School of Law. Professor Knauer came to the
Massachusetts State House in September 2014, and lent her expertise to the
Commission on the topics of: identity, sexuality, and gender; LGBT elders;
and the history and politics of law and policy pertaining to LGBT elders.

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LGBT AGING COMMISSION

RECOMMENDATIONS

INTRODUCTION
The health and well-being of our LGBT older adults has long been neglected. It
is in the spirit of ending the pervasive silence and denial that surrounds LGBT
aging that the Special Legislative Commission on LGBT Aging has developed
its recommendations. The Commission’s recommendations are organized into key
themes. First, we present recommendations that came up across multiple topic areas.
Then, we present specific recommendations within each of the five topic areas: Long
Term Support Services, Public Health, Housing, Senior Centers & Community
Engagement, and Legal Considerations.
While collecting testimonies and holding public listening sessions across the
Commonwealth, the Commission identified a few areas of concern and need that
repeatedly came up for the LGBT aging population. The Commission members worked
in the following critical areas when developing recommendations:
•

Long Term Support Services

•

Housing

•

Public Health

•

Senior Centers and Community Engagement

•

Legal Considerations

Many of the recommendations overlapped across most or all of the areas of focus
mentioned above. The overlapping topics include:

12

•

Data Collection & Needs Assessment

•

Cultural Competency Training & Evaluation

•

Outreach & Access

•

Service Delivery

•

Complaint Resolution

•

Legislation

LGBT AGING COMMISSION

RECOMMENDATIONS

Overarching Recommendations
These overlapping and overarching recommendations (key recommendations)
are presented in order to highlight the greatest areas of need that the commission
consistently came across in its investigation, analysis and study.
D ATA C O L L E C T I O N & N E E D S A S S E S S M E N T
Data Collection
Executive Office of Health and Human Services (EOHHS), Executive Office of Elder
Affairs (EOEA) and Department of Housing and Community Development (DHCD)
should collect voluntary and confidential sexual orientation and gender identity or
expression (SO/GI) data as a standard practice for individual assessments, program
monitoring data systems, consumer satisfaction surveys, public health surveillance,
research and evaluation.
Needs Assessments
EOHHS, EOEA and DHCD should comprehensively assess the psycho-social,
economic, housing, public health and long-term support service needs of LGBT elders
and caregivers. Particular attention should be given to lesbians, transgender people,
elders of color, immigrants and people with HIV/AIDS, many of whom are marginalized
and have suffered multiple forms of discrimination. The findings from these assessments
should drive state and local social service, public health and housing planning and
development. EOEA should designate older adults with HIV/AIDS a population of
“greatest social need” under the Older Americans Act26 for purposes of program
planning and development, and mediate re-designation of LGBT elders as a population
of “greatest social need.”
T R A I N I N G & E VA L U AT I O N
Provider Training
EOHHS, EOEA, DHCD and the state Probate Court should ensure that their staff and
volunteers, as well as those of their vendors, affiliates and licensees, are regularly
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LGBT AGING COMMISSION

RECOMMENDATIONS

Overarching Recommendations
T R A I N I N G & E VA L U AT I O N

CONTINUED

trained on the provision of open, affirming and non-discriminatory service and care for
LGBT elders and caregivers. Relevant vendors and affiliates include, but are not limited
to: councils on aging, senior centers, Area Agencies on Aging (AAAs), Aging Service
Access Points (ASAPs), Independent Living Centers (ILCs), Senior Care Option (SCO)
Plans, One Care Plans, home care and certified home health agencies, adult day health
centers, assisted living facilities, nursing homes and rehabilitation centers, supportive
and congregate housing sites, local housing authorities & senior housing developments,
Housing Consumer Education Center (HCECs) and Serving the Insurance Needs of
Everyone (SHINE) programs, substance abuse and behavioral health providers, and
veterans services agents.
Professional Development
State licensing boards for relevant professions—including but not limited to physicians,
psychiatrists, psychologists, nurses, nursing assistants and social workers–should
require training on LGBT cultural competency.
Consumer Education
DHCD and EOEA should educate residents of senior housing complexes and
participants at Councils on Aging Senior Centers about the importance of inclusion and
open-mindedness toward LGBT older adults.
Best Practices
EOHHS, EOEA and DHCD should regularly evaluate provider and resident/consumer
trainings to assess the extent to which LGBT access, utilization and satisfaction
improves. Vendors, affiliates and licensees that exhibit significant improvements should
be recognized based on a rating system similar to the Human Rights Campaign’s
Health Equality Index for health care providers. EOEA should also develop best practice
standards for LGBT-inclusive programs, services and engagement techniques that can
be replicated at Senior Centers and other community settings used by older adults.
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LGBT AGING COMMISSION

OUTREACH AND ACCESS
Outreach
Outreach strategies should be developed and implemented by relevant state agencies to address
the following areas of significant concern for LGBT older adults.
Advance Planning
EOEA should develop an aggressive public outreach campaign that promotes advance planning
among older adults and that addresses the unique circumstances of LGBT people.
Public Health
EOHHS and EOEA should promote aggressive campaigns that focus on public health issues that
disproportionately impact LGBT older adults. These include HIV prevention, suicide prevention,
substance abuse and social isolation, especially among marginalized groups such as older gay and
bisexual men, LGBT elders of color, immigrants, transgender people, and people living with HIV.
Abuse & Neglect
EOEA should require local elder protective service agencies to include local LGBT organizations
and affiliations in mandated community outreach and education efforts.
Veterans Services
The Massachusetts Department of Veteransâ&#x20AC;&#x2122; Services should conduct outreach to LGBT veterans to
improve utilization of available benefits and services.
Access
Access to aging services should be improved to address the following areas of significant concern.
Anti-Bullying & Harassment
DHCD and local housing authorities should promote the development of open and affirming support
groups in senior housing similar to the Gay Straight Alliances in high schools.

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LGBT AGING COMMISSION

O U T R E A C H A N D A C C E S S CONTINUED
Information & Referral
EOEA should require that its statewide information and referral service and local AAAs,
ASAPs and Council on Aging information and referral services include comprehensive
and up-to-date data on LGBT-inclusive aging services. DHCD should require that HCECs
provide comprehensive and up-to-date data on LGBT-inclusive elder housing.
Registries
EOHHS and EOEA should develop registries of inclusive and competent LGBT
hosts for the Adult Foster Care (AFC) program, LGBT-inclusive workers for the
Personal Care Attendant (PCA) program, and LGBT-inclusive guardians for state
guardianship programs.
Massachusetts Equality and Inclusion Index
The Commission recommends the establishment of a “Massachusetts Equality and
Inclusion Index,” modeled after the Human Rights Campaign’s Health Equality Index, to

16

LGBT AGING COMMISSION

measure how agencies and service providers are treating older adults who are gay,
lesbian, bisexual and transgender. The Equality and Inclusion Index would be based
on a survey sent to all housing facilities (public, private, assisted living, nursing
homes, shelters etc.) as well as Senior Centers, Councils of Aging and elder service
providers. Organizations would be rated on a scale from 0 to 100 percent on several
key indicators of fair treatment for LGBT seniors. Indicators could include policies
prohibiting discrimination based on sexual orientation or gender identity, existing
diversity statements, programs and/or resources specifically for LGBT older adults and
caregivers, LGBT cultural competency training for staff, management and consumers.
Such a ranking system would provide the critical information to all seniors as they begin
to make significant choices about their final years. A ranking system like this would also
reveal inconsistencies with other facilities that market themselves to be LGBT friendly but
have no LGBT programs or any commitment to diversity. A ranking system would also
greatly assist staff at the Massachusetts Housing Consumer Education Centers when
LGBT adults inquire about their housing options and seek LGBT inclusive referrals.

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LGBT AGING COMMISSION

RECOMMENDATIONS

Overarching Recommendations
S E R V I C E D E L I V E RY
Care Planning/ Personal Needs Assessments
EOHHS and EOEA should require that all state and vendor assessment forms should
allow consumers and applicants the right to voluntarily identify their sexual orientation
and gender identity or expression. Such information, which shall be kept strictly
confidential, should be used to develop appropriate, person-centered individual
service plans.
Aging Services
EOEA should insure that there is at least one LGBT-inclusive aging service program,
service or activity in every AAA region; that every local SHINE program has at least
one LGBT-competent counselor; that an LGBT-inclusive “naturally occurring retirement
community” and/ or “virtual senior center” is piloted; and that best practices for
LGBT-competent program development and outreach are collected and disseminated
throughout the network.
Non-Aging Services
EOHHS should insure that those human services programs most relevant to the needs of
older LGBT people, including, substance abuse, behavioral health, suicide prevention,
domestic violence, emergency shelter and veterans services, have at least one LGBTinclusive component.
Housing Promotion
DHCD and EOEA should promote the development of innovative senior housing models
that affirm the need for peer support and open, affirming and appropriate care for LGBT
elders. Specific recommendations include the inclusion of LGBT housing needs in state
Qualified Application Plan (QAP) scores, the creation of LGBT-inclusive small group
homes through a pending 1915 Medicaid waiver to CMS and the development of a pilot
LGBT-inclusive Naturally Occurring Retirement Community (NORC).

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LGBT AGING COMMISSION

People with HIV/ AIDS
EOEA should make people under the age of 60 with functional impairments due to HIV/ AIDS eligible
for the state home care program.
Homeless
EOHHS and DHCD should develop best practices for safely and affirmatively sheltering homeless
LGBT elders.
COMPLAINT RESOLUTION
Ombudsperson
EOHHS should create an LGBT ombudsperson to ensure the integration of LGBT concerns into
the Commonwealth’s aging and human services networks, and to advocate for LGBT elders who
experience barriers to accessing and utilizing services as whole human beings.
L E G I S L AT I O N
The Special Commission on LGBT Aging
The Legislature should extend the commission. The purpose of this extension is to monitor
the implementation of its recommendations and make new recommendations as needs and
circumstances warrant.
Other Legislation
The Legislature should pass additional legislation that:
• Mandates LGBT cultural competency training for state-funded aging services, long-term support
services, and housing services.
• Prohibits discrimination against transgender persons in public accommodations.
• Allows spouses to be caregivers under the Personal Care Attendant (PCA) program.
•

Grants transgender persons the right to have their lived gender reflected on death certificates.

19

LGBT AGING COMMISSION

RECOMMENDATIONS

Long Term Services and Supports
INTRODUCTION
Long-term services and supports (LTSS) are defined as the services and supports used
by individuals, regardless of age, with functional limitations and chronic illnesses who
need assistance to perform routine daily activities such as bathing, dressing, preparing
meals, and administering medications. More than 3 million people in the United States,
the vast majority of whom are elderly, rely on publicly-funded LTSS, which are provided
in skilled nursing facilities, at home, and in community-based settings. The principal
source of funding for LTSS is Medicaid, which in Massachusetts is called MassHealth.
LTSS is of growing interest to both the general public and policy makers because of two
demographic facts: First, people are living longer, with the fastest growing age cohort
being people 85 years or older; second, people are aging with higher rates of disability
than ever before. It is currently estimated that 70% of those who live to 65 will need long
term support services for a considerable period of time before they die.27

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LGBT AGING COMMISSION

P R O B L E M S TAT E M E N T
There is significant evidence that LGBT older adults are in greater need
of long-term services and supports at earlier stages of life than are nonLGBT older adults. This is largely because of two significant demographic
differences between LGBT and non-LGBT older adults:
1. LGBT people are less likely to be partnered or married than
non-LGBT people; and
2. LGBT people are more likely to be childless than non-LGBT people.
Additionally, LGBT older adults are more likely to be estranged from both
immediate and extended family, which often provide supportive services to their
non LGBT counterparts. Since spouses, partners and children are the principal
caregivers for older adults with functional impairments, the lack of familial
resources increases the need of LGBT older adults to rely on publicly-funded
LTSS. A growing body of research has documented lesbian, gay, bisexual, and
transgender health disparities in health and disease outcomes, risk behaviors and
factors, rates of insurance coverage, access to preventive health care, and access
to culturally competent care.28 Research has shown higher rates of disability
among the LGBT population compared to the rest of the general population.29
Despite evidence of greater need, the stateâ&#x20AC;&#x2122;s vast system of public, private and
non-profit LTSS providers are, with rare exception, not equipped to address the
needs and concerns of LGBT older adults and caregivers. Indeed, only a few have
even contemplated the challenge, let alone taken steps to address it. As a result,
LGBT older adults age with significantly limited options: they make do the best they
can with an increasingly fraying â&#x20AC;&#x153;chosen family,â&#x20AC;? then return to the closet in order to
access untrained, outside, professional help who are quite often hostile to minority
sexual orientations and gender identities and expressions. This process often ends
tragically when an older LGBT requires a nursing home and endures the same
bullying, name-calling and harassment experienced earlier in life when coming out.
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LGBT AGING COMMISSION

RECOMMENDATIONS

Long Term Services and Supports
P R O B L E M S TAT E M E N T

CONTINUED

It is with the goal of ending that tragic cycle that the Commission has proposed the
following recommendations. These address four general areas for improvement in the
following deficits in the Commonwealth’s long term care system:
•

The lack of LGBT knowledgeable and inclusive aging service providers
and programs;

•

the absence of sexual orientation and gender identity and gender expression in
individual and community-wide needs assessments and program evaluations;

•

insufficient outreach to mitigate historic and deeply-held mistrust by LGBT older
adults of mainstream systems; and

•

vulnerability of LGBT older adults to bullying and harassment in state-funded aging
programs and services.

While the Massachusetts LGBT Aging Commission has resisted prioritizing its
recommendations, it strongly believes that these two are foundational:
Provider Training
All relevant state agencies (EOHHS, EOEA and DHCD) and their provider/facility
networks should undergo regular and recurring training on how to appropriately and
affirmatively serve and outreach to LGBT older adults.
Self-Identification
Relevant state assessment and program evaluation tools and systems should recognize
sexual orientation and gender identity as critical to care planning and offer consumers
opportunities for safe self-identification and self-expression.
Without the implementation of these critical recommendations the Commission believes
little progress can be made in the additional recommendations which are grouped
under access and outreach; data collection; research and planning; service delivery,
and legal issues.

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LGBT AGING COMMISSION

Access, Training & Outreach
The following specific recommendations are made to address the historic mistrust on
the part of LGBT older adults and their caregivers of mainstream service delivery
systems, and their resulting reluctance to access help even when it is critically needed.
•

State legislation should be enacted to ban discrimination in public accommodations
based on gender identity and/or expression. EOHHS, EOEA and DHCD regulations
and contracts should prohibit discrimination against LGBT people in service delivery
and employment.

Relevant secretariats and departments should mandate regular & recurring training
on sexual orientation, gender identity and gender expression for staff of state
agencies providing or administering services to LGBT older adults, including
probate courts, as well as the staff and volunteers of all relevant licensees,
contractors and subcontractors, including Area Agencies on Aging (AAA)/
Aging Access Service Points (ASAPs); home care, home health, veterans service
and subsidized housing providers; Independent Living Centers (ILCs) and Aging
and Disabilities Resource Centers (ADRCs); assisted living and skilled nursing
facilities; and substance abuse and behavioral health counseling services.

•

Relevant state licensing boards should require LGBT cultural competency training
for professional certifications.

•

Relevant state agencies should develop and apply best practices for full inclusion,
cultural competence, and equality of LGBT people by contractors and licensees;
and develop and apply standards for the assessment of compliance which findings
shall be made public.

•

Relevant state agencies should mandate that contractors and licensees assess
experiences of LGBT consumers in well-designed consumer satisfaction surveys.

•

EOHHS should establish a “cross secretariat” LGBT ombudsperson to address
harassment, bullying and discrimination in delivery of aging services and activities.

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LGBT AGING COMMISSION

RECOMMENDATIONS

Long Term Services and Supports
Access, Training & Outreach
•

CONTINUED

EOEA should maintain designation of LGBT older adults as a population of “greatest
social need” under the Older Americans Act, as was designated by Massachusetts
Elder Affairs Secretary Ann Hartstein in 2012; EOEA should also designate older
adults living with HIV/AIDS as a population of “greatest social need” under the Older
Americans Act (OAA)30 for state and local Area Agency on Aging planning and
program development.

•

EOEA should include information on LGBT-inclusive and culturally competent
aging supports and services at 1-800-AGE-INFO, and should require local AAA/
ASAP information and referral services to do the same.

•

EOEA should require protective service agencies to conduct outreach and
education to local LGBT communities and individuals.

•

EOHHS & EOEA should develop and apply best practices in promoting and
assessing the participation of and development of registries for LGBT-inclusive AFC
hosts, PCAs and state-funded guardians/conservators.

The Massachusetts Department of Veterans’ Services should conduct outreach to
LGBT veterans to increase utilization and development of necessary and
appropriate veteran benefits. This is essential given the history of expulsion and
persecution of gay, lesbian and bisexual service members, many of whom were
given dishonorable discharges, as well as the continued exclusion of transgender
service members. Many LGBT veterans do not know they are eligible for benefits,
or do not know about the national Veterans Health Administration directives
guaranteeing high quality, welcoming, and nondiscriminatory health care for gay,
lesbian and bisexual veterans31 and for transgender veterans.32

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LGBT AGING COMMISSION

Data Collection, Research and Planning
The following specific recommendations are made so that LGBT older adults and their
caregivers can identify their sexual orientation and/or gender identity and expression for
personal care and program/community planning and evaluation purposes.
•

EOHHS, EOEA and DHCD program applications and personal assessment tools
should encourage applicants and consumers to safely identify sexual orientation,
gender identity, gender expression (including preferred pronoun) and relationship
status for themselves and relevant caregivers. EOHHS should collect data on
the experiences of LGBT older adults, including: LGBT veterans, LGBT people of
color, people with HIV/AIDS, immigrants, non-English speakers, formerly
incarcerated individuals, the homeless and the incapacitated. These agencies
should publish periodic reports on disparities in access, utilization and outcomes.

•

EOEA should assess the economic status of LGBT older adults (especially lesbians
and transgender people) and older adults living with HIV/AIDS and their vulnerability
to abuse, neglect and financial exploitation, as part of the next OAA-mandated
state planning process. Based on this assessment, EOEA should assess whether
these populations should be designated as elders with “greatest economic need” 33
as per the Older American Act.

•

State secretariats should publish an annual assessment of service delivery to
transgender older adults every November in conjunction with Transgender
Awareness Month.

….. if you look at a map of where they come from,
some travel great distances and why are they doing
that? It’s because they don’t feel that there are
sensitive healthcare providers in closer proximity.

“

“

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LGBT AGING COMMISSION

RECOMMENDATIONS

Long Term Services and Supports
S E R V I C E D E L I V E RY
The following specific recommendations are made to address the limited LGBTinclusive and culturally competent aging service options for LGBT older adults and their
caregivers, as well as the harassment and bullying that LGBT older adults and their
caregivers experience when accessing mainstream aging services, resources
and activities.
•

EOEA should ensure that every Area Agency on Aging supports at least one
LGBT-inclusive and culturally competent program, service or activity, and that
every Aging Service Access Point has at least one verified LGBT-inclusive and
culturally competent home care vendor.

•

EOHHS should ensure that every program area relevant to the needs of LGBT older
adults, including substance abuse, behavioral health, suicide prevention, domestic
violence, emergency shelter, and veterans services, has at least one LGBT-inclusive
and culturally competent component.

•

EOHHS should make spouses eligible caregivers for the Personal Care Attendant
(PCA) program and for other consumer-directed long-term support services.

•

EOHHS and EOEA should request federal waivers to allow for small “group homes”
for nursing home eligible elders and, if approved, create at least one LGBTinclusive and culturally competent home as an alternative to nursing homes.

•

DPH and EOEA should collaborate on the development and dissemination of an HIV
prevention campaign that targets older adults in senior centers, senior housing,
assisted living, adult day programs, congregate meal and supportive housing sites,
naturally occurring retirement communities (NORCs), nursing homes, and other
relevant venues.

•

EOEA should make people under the age of 60 with functional impairments due to
HIV/ AIDS eligible for state home care services.

•

DHCD should develop best practices for safely and affirmatively serving LGBT
people in homeless shelters.

26

LGBT AGING COMMISSION

•

EOEA should plan the development of an LGBT inclusive and competent
“naturally occurring retirement community” (NORC).

•

EOEA should develop LGBT-specific counseling competency within at least
one regional Service the Health Insurance Needs of Everyone (SHINE) Medicare
counseling program.

•

EOEA should develop a statewide campaign to promote and facilitate
LGBT- friendly, inclusive and culturally competent advance planning among older
adults that includes explicit opportunities to safely identify sexual orientation and
gender identity and expression.

•

EOHHS, EOEA and DHCD should support the development of social networks
of LGBT older adults at high risk of isolation, including: veterans, persons of
color, immigrants, non-English speakers, people living with HIV/AIDS, ex-prisoners
and the disabled.

27

LGBT AGING COMMISSION

RECOMMENDATIONS

Public Health
INTRODUCTION
Public health examines the relative risks of health issues facing a given population
and guides responsive efforts to prevent disease and promote health. Like younger
members of the LGBT community, LGBT elders may be at disproportionate risk of certain
infectious diseases, interpersonal violence, suicidality, substance abuse, mental health
concerns, certain cancers, and possibly chronic conditions, such as asthma.

When an elder has been moved to a nursing home, suddenly you feel like you’ve lost
control. But I think, for somebody who’s LGBT, going into a nursing home, it’s more

“

“

like a panic that they will not get the care that is needed. I think programs need to
have training.

D ATA C O L L E C T I O N
The lack of systematically collected health data on LGBT individuals complicates the
ability to draw conclusive conclusions about their relative risks and plan prevention
and risk mitigation efforts. Population-level data collection (such as the federally
funded, state-administered Behavioral Risk Factor Surveillance System or BRFSS) can
help estimate these risks by enabling correlational and odds ratio analyses between
selected risks and LGBT identities or same-sex behaviors. They also can help establish
estimates of the size of the LGBT community, which are useful demographic findings
in themselves. In addition, by providing estimates of the size of the LGBT community
or subpopulations such as lesbians, and the percentage of different age cohorts that
identify as LGBT, population studies permit the calculation of case rates for various
health risks and outcomes for comparison to other populations, a standard type of
analysis in public health. Special studies and program delivery data which collect
information on sexual orientation and gender identity and expression, while potentially
not representative of the entire LGBT elder population, can provide needed contextual
detail and information about the degree to which existing and planned services reach
LGBT elders as planned.

28

LGBT AGING COMMISSION

SUICIDE PREVENTION & SERVICES
According to the American Foundation for Suicide Prevention (AFSP), the second
highest suicide rate was found in people over the age of 85. AFSP also documents
a heightened risk of suicide attempts among LGBT people.34 LGBT veterans have
a higher rate of suicide than other veterans, and veteran suicide rates are already
elevated.35 LGBT elders may face compounded risk.36 Because of high rates
of depression and isolation in LGBT elders, it is important for the Massachusetts
Department of Public Health to address the issue of suicide prevention specifically for
this population.
INFECTIOUS DISEASE RISK
The disproportionate impact of HIV, syphilis, and other sexually transmitted infections
on men who have sex with men (MSM) is well established in Massachusetts and other
jurisdictions.37 Nationally about two thirds of newly reported HIV infections38 and over
three quarters of newly reported cases of infectious (primary and secondary) syphilis39
are among gay and bisexual men. Black MSM are disproportionately burdened.40 The
majority of prevalent (living) cases of HIV/AIDS in MSM are among men over the age of
50. The collection of data on transgender identity or expression is relatively new in HIV
surveillance, and data estimates remain unreliable. However, CDC data indicate that
transgender women are at very high risk of HIV infection, especially Black transgender
women,41 risk that may accumulate over time and with age. About half of people living
with HIV in the U.S. today are age 50 or older.42 The generation born between 1945
and 1965 is at higher risk of hepatitis C infection related to medical procedures as well
as individual drug use and sexual behaviors earlier in life. The U.S. Centers for Disease
Control and Prevention have recommended all members of this age cohort be screened
for hepatitis C infection.43 LGBT elders falling into this generation may be at elevated
risk of hepatitis C due to higher rates of historic or ongoing individual risk behaviors.

29

LGBT AGING COMMISSION

RECOMMENDATIONS

Public Health
CANCER RISK
Cancer risks of LGBT people have been studied for well over a decade, with most
information gained about lesbians and gay men. In the CDCâ&#x20AC;&#x2122;s 2012 National Adult
Tobacco Survey, LGBT rates of tobacco use were 68% higher than others in the US
(31% of LGBT people smoked compared with 21% of heterosexual adults).44 The
2011 Institute of Medicine Report on LGBT health describes possibly higher rates of
breast cancer among lesbians related to nulliparity (never having given birth). Gay
and bisexual men are at elevated risk of anal cancer related to higher rates of Human
Papilloma Virus (HPV). Transgender men on testosterone therapy may experience
elevated risk of ovarian cancer, and transgender women taking feminizing hormones
can experience prostate cancer.45 LGBT people also experience higher rates of post
traumatic stress disorder (PTSD), 46 mood disorders, depression and anxiety. 47
Lesbians and bisexual women receive less routine health care than other women,
including colon, breast and cervical cancer screening tests.48 49 Other risks for cancer
in these populations are smoking, obesity, drinking alcohol, nulliparity, not having breast
fed, and not having used contraceptives. Among these risks, smoking is the greatest risk
for lung cancer among lesbian and bisexuals. HIV-positive smokers lose an average of
12.5 years of life, compared to 5.1 for HIV-positive nonsmokers. Primary cancer risks in
gay and bisexual men are HPV infection, lung cancer, prostate cancer (more common in
African American gay men) and colon cancer in men older than 50. Anal sex with many
sex partners presents additional risk of cancer. 50
S U B S TA N C E A B U S E
Multiple studies have documented higher rates of alcohol and other substance use and
abuse among LGBT adolescents and adults, and these trends appear to extend into
later age among LGBT individuals.51 However, programs targeting this population have
been limited and treatment environments may not be perceived as safe or responsive to
elder LGBT individualsâ&#x20AC;&#x2122; life circumstances and histories of trauma and discrimination.52 53

30

LGBT AGING COMMISSION

Public Health Recommendations of the Massachusetts LGBT Aging Commission
D ATA C O L L E C T I O N
The Commission recommends that the Massachusetts Department of Public Health
and its reporting partners work toward including sexual orientation, gender identity, and
gender expression as core demographic measures in its surveillance, public health
research and evaluation, and program monitoring data systems, particularly those
systems which examine the health of elder residents of the Commonwealth, and perform
longitudinal analyses of existing datasets containing data on these residents.
The Commission also recommends that the Massachusetts Department of Public
Health identify published literature and best practices around the collection of sexual
orientation, gender identity, and gender expression via clinical encounters, interviews,
surveys, and self-reported data collection systems, with particular attention to
confidential collection methods, including those that do not require spoken responses.

The things that are necessary, that are essential for older people in

â&#x20AC;&#x153;

â&#x20AC;&#x153;

any community, even LGBT community, is camaraderie, events and
inclusiveness, training in nursing homes.

SUICIDE PREVENTION AND SERVICES
The Commission recommends that the Massachusetts Department of Public Health in
collaboration with the EOEA develop a strong public outreach campaign about suicide
prevention in the LGBT elder communities. This should include materials already
created by the Transgender Suicide Prevention Coalition. The public outreach efforts
should include a listing of resources available for those considering suicide, previous
attempters, and suicide service providers. The Commission further recommends that
the Department of Mental Health develop programming to identify and address mental
health concerns, including major depression, among LGBT elders.

31

LGBT AGING COMMISSION

â&#x20AC;&#x153;
RECOMMENDATIONS

Public Health Recommendations of the MassachusettsLGBT Aging Commission
HIV PREVENTION
The Commission recommends that the Massachusetts Department of Public Health
develop HIV prevention education materials for older adults and, in collaboration with
the EOEA and the DHCD, develop and implement an aggressive HIV prevention public
outreach campaign focusing on senior housing, senior centers, congregate meal sites,
naturally occurring retirement communities, adult day health programs and other venues,
services, programs and activities that reach or target older adults.
S E X U A L LY T R A N S M I T T E D INFECTIONS/VIRAL H E PAT I T I S
The Commission recommends that the Massachusetts Department of Public Health
and its reporting partners collect data and examine relative risk of sexually transmitted
infections and viral hepatitis infections among LGBT elders, and identify best practices
for the prevention, screening, and treatment of these infections among LGBT elders.
CANCER PREVENTION AND SERVICES
The Commission recommends that the Massachusetts Department of Public Health
examine its available data on cancer to determine relative risk and other concerns faced
by LGBT elders. The Department should train providers in how to talk with and provide
care for LGBT elders with cancer-related concerns, and involve their friends, partners,
and families in support services and the dissemination of appropriate health information.
S U BS TA N C E A B U S E S E RVICES
The Commission recommends that the Massachusetts Department of Public Health, in
collaboration with the EOEA, develop a strong public outreach campaign on substance
abuse in the LGBT elder communities. The public outreach efforts should include a
listing of resources available.

32

LGBT AGING COMMISSION

I have fears of being left alone if something happens to
(my partner), because I have no family. I’ve seen the discrimination in the early 80s, when my friends were in the
hospital, dying. I was the only one there taking care of
them, because even the healthcare professionals would
not take care of them. I saw that firsthand, and some has
changed, but not much has changed. I never lived a day
in the closet. I have been out my entire life, because I
have always been proud of who I am. But there are a lot
of people who could not do that. But I am thankful that I
was able to do that. And when my friends died, I crawled
in their beds and held them until they died, so they
wouldn’t have to die alone. I did that for all 20 of my
friends, and I’m a sole survivor, and now that I’m going
to need some help, I have fears that it’s not here for me.

“

“

RECOMMENDATIONS

Housing
INTRODUCTION
Over the last ten years Massachusetts has emerged as the nationâ&#x20AC;&#x2122;s leader
in establishing the first network to provide competent care for LGBT elders
through cultural competency training and outreach program supported by the
Massachusetts Executive Office of Elder Affairs. While this work is notable there
is still much to do. It is the work of this Commission, another first in the nation, to
ensure that Massachusetts continues to serve as the model for inclusive service
delivery for all older adults. One of the areas where Massachusetts is lagging
behind is in its commitment to address the housing needs of LGBT older adults.
The positive contributions in Massachusetts in areas such as competent service
delivery and programming are overshadowed by the undisputed absence of safe,
welcoming, publicly-funded housing for LGBT older adults. Studies conducted
across the country show that housing is one of the top concerns shared by older
LGBT adults.54
Over one hundred LGBT older adults across the Commonwealth testified during the
Commissionâ&#x20AC;&#x2122;s four listening sessions to the growing fear related to the lack of safe
housing options. This is a national concern that we heard strongly echoed by LGBT
citizens of Massachusetts. Therefore the Commission would like to make the following
recommendations that address three specific areas: 1) the need for the development
of LGBT friendly housing options in Massachusetts; 2) the need to make existing
public housing safe and welcoming for all people, including LGBT elders; and 3) the
development of systems that would track and identify welcoming housing options and
the commitment to the safety and wellbeing of those living in them.
34

LGBT AGING COMMISSION

Make at least one LGBT friendly housing initiative a priority in
Massachusetts’ urban development plan.
Boston and other Massachusetts cities are lagging behind Los Angeles,
Chicago, Philadelphia and San Francisco, which have all developed vibrant
housing initiatives that are friendly and inclusive of LGBT older adults. These
projects have become symbols of those cities’ commitment to diversity and
inclusion for all people and all generations. Unfortunately, Massachusetts
has nothing like this. The Commission would like to strongly recommend that
such a project be made a priority in the next five years.

But I think the reason staying independent is at the top for LGBT people
is that there’s a lot of fear about what’s going to happen to me if I can’t

“

“

maintain myself, because we as a community don’t have confidence
that the system is there to prop us up, to help us.

Conduct a comprehensive needs assessment of the housing needs for
LGBT older adults.
Before launching into any housing initiatives such as the one outlined above,
it is imperative that data be collected to quantify the specific housing needs
for LGBT older adults in Massachusetts. This work should take the form of a
comprehensive Housing Needs Assessment that would be given at different
locations across the state. The results from a housing needs assessment
would provide city planners with the information necessary to move forward
with the appropriate types of housing needed and the locations required for
those projects.

35

LGBT AGING COMMISSION

36

LGBT AGING COMMISSION

RECOMMENDATIONS

Housing
Develop LGBT friendly group and rest homes through the 1915 Waiver.
Most older adults fear possible placement in a nursing home. For LGBT older
adults, this fear is intensified by a near complete lack of privacy and the often
intense homophobia of facility staff, residents and visitors. Many LGBT older
adults refer to nursing homes as “institutional closets,” and say with great
conviction that they would rather die than be placed in one. At the same time,
many LGBT older adults, like many non-LGBT older adults, will need skilled
nursing care to manage end-of-life care, dementia and other advanced chronic
conditions. Small “group homes” are increasingly considered more empowering
and “person-centered” alternatives for elders who need nursing home level
of care. While these would require a federal waiver of Medicaid rules, their
implementation would be a boost for frail and severely disabled LGBT adults who
want the last stage of their lives to be as LGBT inclusive and culturally competent
as possible.
Launch an ad-hoc committee to examine the development of an
LGBT-inclusive Naturally Occurring Retirement Community (NORC)
pilot in Massachusetts.
The village model of neighborhood living and shared services has been a
successful and increasing model across the country. One of the forerunners in
this movement is Beacon Village in Boston, which can serve as a model for a
similar project with LGBT older adults. LGBT adults have always sought safety
in numbers and have often clustered themselves in specific sections of a city.
The Commission recommends the development of an ad hoc committee to look
into the establishment of an LGBT friendly NORC that could be explored in one
of the established gay neighborhoods in Boston (Jamaica Plain, Roslindale or
Dorchester) or even in a less densely populated area with a high percentage of
older LGBT adults such as Orleans.55

37

LGBT AGING COMMISSION

RECOMMENDATIONS

Housing
Design and implement a curriculum module for cultural competency training
around LGBT older adults for all housing management and staff and a separate
education module for residents.
The Commission feels it is important to adopt a two-tiered approach to address the
housing crisis for LGBT elders. The first tier, as outlined above, would encourage the
development of new LGBT inclusive housing initiatives (new inclusive affordable housing
units, NORCs, group and rest homes). The second tier would address housing equality
by ensuring that all existing public senior housing begin the process of becoming
welcoming to all people, including LGBT adults. The best way to meet this goal is
through cultural competency training and education. The training would be for all levels
of management and staff at current buildings. The Commission recommends mandatory
cultural competency training similar to the version currently used for elder service
providers through the EOEA. A second and equally critical phase to this training is the
development of a curriculum to help educate current residents about the lives of LGBT
older adults. Most LGBT elders fear their non-LGBT peers more than they fear housing
staff or health providers. It is not fair to make the LGBT elders themselves responsible
for educating and changing the climate in each public housing building from a place
of hostility to a place of acceptance. That responsibility belongs to the management
through the gentle education of the residents. To keep this effort sustainable and alive
year-to-year, the Commission recommends a routine refresher course for management
and residents and a yearly in-service (with continuing education units, or CEUs) for all
Resident Coordinators.

38

LGBT AGING COMMISSION

Identify â&#x20AC;&#x153;under-served populationsâ&#x20AC;? (including LGBT people) as target groups in
the Qualified Allocation Plan (QAP).
The Department of Housing and Community Development is the state agency charged
with allocating the federal Low Income Housing Tax Credits (LIHTC). The United States
Treasury requires that the Department prepare an annual plan, a Qualified Allocation
Plan (QAP), which describes the method of allocation of those credits. The other federal
and state housing funds and tax credits that DHCD oversees are also allocated through
the competitive process outlined in the QAP.
One of the categories into which a proposed housing development must fit is for
extremely low-income (ELI) individuals, families, and seniors, i.e., households earning
less than 30% of the area median income. Projects in this category must be supported
by tenant services and include at least 20 percent ELI units. Projects can serve families
or individuals, seniors, persons with disabilities, and persons with special needs.
The Commission recommends that language identifying under-served populations be
added to the list of specified target groups. Even though projects serving LGBT seniors
and other under-served populations are eligible for funding through the competitive
rounds, this language will clarify that groups whose housing needs have not been
served, including LGBT seniors, will be noted in the application process.

39

LGBT AGING COMMISSION

RECOMMENDATIONS

Housing
Develop a ratings system that will evaluate the level of inclusiveness for senior
housing buildings in Massachusetts.
At the present moment there are a number of individual housing facilities (Assisted
Living, retirement communities and rest homes) in Massachusetts that are working to
become LGBT friendly housing options. Although this is certainly a step in the right
direction, there is a lack of any system that evaluates current or future senior housing
buildings in terms of their commitment to diversity and their inclusiveness in welcoming
LGBT older adults into their community.
As noted earlier, the Commission recommends the establishment of a â&#x20AC;&#x153;Massachusetts
Equality and Inclusion Indexâ&#x20AC;? to measure how agencies and service providers are
treating older adults who are LGBT. The Equality and Inclusion Index would be based
on a survey sent to all housing facilities (public, private, assisted living, nursing
homes, shelters etc.) as well as Senior Centers, Councils of Aging and elder service
providers. Organizations would be rated on a scale from 0 to 100 percent on several
key indicators of fair treatment for LGBT seniors. Indicators could include policies
prohibiting discrimination based on sexual orientation or gender identity, existing
diversity statements, programs and/or resources specifically for LGBT older adults and
caregivers, LGBT cultural competency training for staff, management and consumers.
Such a ranking system would provide the critical information to all seniors as they begin
to make significant choices about their final years. A ranking system like this would
also reveal inconsistencies with other facilities that market themselves to be LGBT
friendly but have no LGBT programs or any commitment to diversity. A ranking system
would also greatly assist staff at the Massachusetts Housing Consumer Education
Centers when LGBT adults inquire about their housing options and seek LGBT inclusive
referrals.

40

LGBT AGING COMMISSION

Identify an LGBT Liaison in the Housing Consumer Education Centers (HCECs) for
the purpose of education, information and referral regarding LGBT-inclusive senior
housing, LGBT senior housing, and related issues. Ensure that HCECs are briefed
on the issues and have responses available to LGBT people seeking assistance.
The Commission recommends that at least one staff member at the Metropolitan Boston
Housing Partnership Inc. be trained as a liaison to the LGBT community to assist with
any housing referrals from LGBT older adults. The other HCECs would be aware of this
liaison and send any LGBT clients to them. The information regarding established LGBT
friendly housing facilities would come from the data collected in the Massachusetts
Equality Index (see previous Recommendation).
Within EOEA, create an Ombudsperson at the state level for LGBT aging issues.
For many years local professionals in the field of LGBT aging have felt that the people
who are already ensconced in nursing homes and assisted living facilities are so
closeted that we may never find or engage with them. There is a critical need for the
development of a LGBT Ombudsperson to monitor the wellbeing of our LGBT elders
in residential facilities across the state. This person could also provide training to other
Ombudspeople so that they would become more knowledgeable about the needs and
concerns of LGBT elders.
Assess the need for LGBT inclusive shelter
Currently there are no homeless shelters serving older adults that are designated
as LGBT friendly and culturally competent shelters. The Commission recommends
assessing the need for at least one shelter to go through the training outlined above
and be established as a safe and welcoming place for LGBT homeless adults.

41

LGBT AGING COMMISSION

RECOMMENDATIONS

Housing
Pass the equal access in public accommodations bill.
The Commission also supports the passage of the equal access bill in public
accommodations, which would protect the right of transgender elders to live
without fear of discrimination in any public housing, including nursing homes,
as well as the ability to access other important public accommodations, such
as public transportation, retail establishments, health centers, and parks.56

Promote innovative senior housing models to meet the needs of
LGBT elders.
DHCD and EOEA should promote the development of innovative senior
housing models that affirm the need for peer support and open, affirming
and appropriate care for LGBT elders. Specific recommendations include
the inclusion of LGBT housing needs in state Qualified Application Plan
(QAP) scores, the creation of LGBT-inclusive small group homes through
a pending 1915 Medicaid waiver to CMS, and the development of a pilot
LGBT-inclusive NORC.

Prevent bullying and harassment of LGBT elders in senior housing.
DHCD and local housing authorities should promote the development of
open and affirming support groups in senior housing similar to the Gay
Straight Alliances in high schools.

42

LGBT AGING COMMISSION

43

LGBT AGING COMMISSION

RECOMMENDATIONS

Senior Centers and Community Engagement
INTRODUCTION
The Commission considered the ability of each community to provide programs,
including meeting places that older members of the LGBT community could
congregate and receive services and information. This focus was on the
Commonwealth’s network of established Councils on Aging (COAs), although
these recommendations could be replicated in other community-based and even
residential settings.
P R O B L E M S TAT E M E N T
LGBT people reside throughout our Commonwealth, yet without any LGBT community
centers, locations where LGBT residents gather are few and far between. The
Commonwealth should develop a network of locations that can provide services and
programs for LGBT older adults by utilizing our Commonwealth’s established network of
COAs. Furthermore, we recommend that staff of all COAs be trained about the needs of
LGBT populations and ways to welcome these residents into every Senior Center.
History of Executive Office of Elder Affairs (EOEA) and Massachusetts Association
of Councils on Aging (MCOA) LGBT Aging Project
In 1954 enabling legislation established the ability of each city and town to establish a
“COA” to meet the needs of seniors within their community. Beginning in 1971, the EOEA
made a concerted effort to build a statewide network of senior centers. Since 1979
EOEA has partnered with the MCOA to strengthen this network through training and
technical assistance while promoting best practices and funding initiatives that promote
innovation and regionalization.
Currently 349 communities have established municipally based Councils on Aging.
Many provide a full range of services, but we also recognize that approximately 50 of
these COAs are mostly volunteer-driven and have limited capacity to develop or initiate
new programs. We recommend that EOEA and MCOA establish a formal partnership
with an organization experienced in LGBT cultural competency training to collaborate
and help implement the commission’s recommendations.
44

LGBT AGING COMMISSION

DEMOGRAPHICS
According to the April 1, 2010 US Census there were 1,273,186 older adults in our Commonwealth.
Projections from EOEA (2002 Miser Report) anticipate that another 360,000 older adults will be
added to the population age 60 or older by 2020. Furthermore, these demographics indicate that
as of 2010, the total older adult population was 19% of the Commonwealth’s population; within a
decade older adults will comprise 25% of our state population. If 5% of the Commonwealth’s older
adults are LGBT, we project that within five years, over 80,000 LGBT older adults will reside in the
Commonwealth. By 2020 this will mean that the median town of 19,500 will include approximately
230 LGBT older adult residents.
U N D E R S TA N D I N G T H E C O M P L E X I T I E S
The Commission heard testimony about the various needs of the LGBT communities and recognizes
that community-based services and programs need to be tailored meet the diverse needs of each of
the lesbian, gay, bisexual and transgender communities. Of particular focus is the need for increased
understanding and sensitivity of the needs of our Commonwealth’s transgender communities, with an
emphasis on educating our workforce about their specific needs. The combination of COA limitations
in some communities and the complexity of needs of the LGBT communities present challenges to
addressing these needs, given limited resources and staffing at the local level.
From that baseline challenge come recommendations to provide across-the-board cultural competency
training for COA staff and volunteers, and the development of regional locations where services and
programs could be offered to the LGBT populations.
All staff and volunteers who work with older adults should receive LGBT cultural competency training.
There is also a need for community education, the identification of the best practices for serving LGBT
elders and the development of an index to score these programs, and specific legislative and regulatory
changes to make our Commonwealth more inclusive and supportive for LGBT older adults.
.

45

LGBT AGING COMMISSION

RECOMMENDATIONS

Senior Centers and Community Engagement Recommendations
Establish regional locations at existing Councils on Aging/Senior Centers that will
provide services and programs to the LGBT older adult population that include but
are not limited to transportation, outreach, and socialization opportunities.
Since not every senior center or COA can address all of the needs of LGBT elders, the
EOEA and MCOA support the establishment of regional senior centers throughout the
Commonwealth that can provide the services and programs to these populations as
needed. In conjunction with other community-based organizations, including the ASAP/
AAA network, one or more municipally-based COAs should be designated to be a focal
point for LGBT services within that region. Furthermore, EOEA should prioritize LGBT
services within the current COA Service Incentive Grant Program to provide seed monies
to establish program and services.

46

LGBT AGING COMMISSION

Create a virtual LGBT senior center.
To fill potential gaps that might initially arise with the first recommendation, and
in recognition that many LGBT older adults may wish to retain their privacy, the
commission strongly recommend the development of a virtual senior center that could
be accessible to all interested parties, providing information and referral as well as
opportunities for socialization. This will require identifying a qualified organization and
sufficient funding of this web-based service to develop and maintain this much needed
service. EOEA and MCOA should be part of this project in an advisory capacity. The
established regional locations described in the first recommendation above should be
linked in to share their calendar of events and available resources.

47

LGBT AGING COMMISSION

RECOMMENDATIONS

Senior Centers and Community Engagement Recommendations
Front line staff of Councils on Aging and other community based organizations
should be continually updated about available resources and services available for
LGBT older adults.
Providing current information is critical for COA outreach workers, ASAP case managers,
and information and referral specialists. The virtual senior center could be the hub of this
information, making local, state and federal resources available to anyone who logged
on. EOEA and MCOA should partner with the implementing organization to ensure that
information remains current and viable.
The implementing organization, in conjunction with EOEA and MCOA, should
maintain an inventory of existing community based programs and services
throughout the Commonwealth.
The purpose of this would be to provide resources for consumers and professionals,
and to identify best practices that can be replicated, and identify gaps in service that
need to be addressed. An ongoing collaboration between these three agencies and
other interested parties should be formalized to ensure quality, promote information
sharing and identify funding opportunities. This collaborative’s mission should to
promote “access to services and programs that meet the needs of the LGBT older
adult population.”
Conduct statewide campaign to make all senior centers welcoming places for all,
including LGBT elders.
MCOA’s goal, embraced and funded by EOEA, is to make each of our senior centers
a “Welcoming Place for All.” A statewide campaign should be developed to let it be
known that senior centers are public buildings where everyone is welcome and everyone
should be treated with respect and dignity. Inappropriate behavior and bullying will not
be tolerated as we seek to celebrate the diversity of our Commonwealth. Behavioral
policies should be adopted locally.

48

LGBT AGING COMMISSION

Legal Considerations
Legislate equal access to public accommodation regardless of gender identity.
Increase explicit legal protections against discrimination on the basis of sexual
orientation, gender identity and expression, and HIV status within the context of
elderly housing (e.g. elder-designated housing, assisted living facilities, and nursing
homes) and services for older adults (e.g. health care, nutritional, and transportation
services), and ensure greater and stronger enforcement of such protections (e.g. state
enforcement, ombudsperson enforcement, and private rights of action).

If you talk about the senior centers, we are not going to them. Why?
Because we don’t feel welcome. When we’re there, we are afraid of
identifying or saying something that may out ourselves, and then finding
out the next person, the person sitting beside us, is not tolerant of that.

“

“

Facilitate the ability of older LGBT adults to plan for decision-making during
periods of incapacity or end of life by providing greater availability and/or options for
elders to be able to designate beneficiaries and agents for various purposes, including
health care and financial decision-making, while ensuring adequate protections against
fraud and elder abuse (e.g. notarizations, witnesses, legal consultations and clinics).
Ensure that transgender individuals can have their lived gender accurately
reflected on death certificates.

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LGBT AGING COMMISSION

CONCLUSION AND NEXT STEPS

Conclusion and next steps
The health and well-being of our lesbian, gay, bisexual
and transgender (LGBT) older adults is an ongoing
concern. This report and the recommendations
herein represent an initial effort to address the severe
prejudice and exclusion that LGBT older adults
have faced all their lives and continue to face today.
Additional work is needed to monitor implementation
of the recommendations of the commission.
Implementation of these recommendations will
enhance the well-being not only of LGBT older adults
but also the quality of life of all older adults across
the Commonwealth.
By implementing these recommendations in full, the
Commonwealth can continue to maintain its visionary
leadership in creating a more inclusive and equitable
society for all.

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LGBT AGING COMMISSION

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LGBT AGING COMMISSION

NOTES

PAGE. 7

1.

Banham R. 2010. Facing the future. When it comes to accepting the need for long-term care

down the road, many opt for denial. Wall Street Journal. http://online.wsj.com/ad/article/longtermcarefuture
PAGE. 8

2.

U.S. Administration on Aging. 2001. Fact sheet: The many faces of aging. Washington, DC. Cited

HIV Infection and Aging: What Is Known and Future Research Directions.” Clinical Infectious Diseases
47(4):542–53. Cited in Cahill S, Valadez R. 2013. “Growing Older with HIV/AIDS: New Public Health
Challenges.” American Journal of Public Health 103(3):e7–e15. doi:10.2105/AJPH.2012.301161.

Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps

and Opportunities; Board on the Health of Select Populations; Institute of Medicine. 2011. The Health of
Lesbian, Gay, Bisexual, and Transgender (LGBT) People: Building a Foundation for Better Understanding.
Washington, DC: National Academies Press

HIV Infection and Aging: What Is Known and Future Research Directions.” Clinical Infectious Diseases
47(4):542–53. Cited in Cahill S, Valadez R. 2013. “Growing Older with HIV/AIDS: New Public Health
Challenges.” American Journal of Public Health 103(3):e7–e15. doi:10.2105/AJPH.2012.301161.

43.

Smith BD, et al, 2012, August 17. U.S. Centers for Disease Control and Prevention,

Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During
1945–1965. Morbidity and Mortality Weekly Report: Recommendations and Reports. 61(RR04);1-18.
PAGE. 30

44.

Agaku IT, et al. U.S. Centers for Disease Control and Prevention. Tobacco Product Use Among

Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps

and Opportunities; Board on the Health of Select Populations; Institute of Medicine. 2011. The Health of
Lesbian, Gay, Bisexual, and Transgender (LGBT) People: Building a Foundation for Better Understanding.
Washington, DC: National Academies Press. Pages 5-16 and 5-17.
46.

Second state to pass a sexual orientation nondiscrimination law (1989).

•

First state to create Governor’s Commission on Gay and Lesbian Youth (1992);
current Massachusetts Commission on LGBTQ Youth is still the only one of its kind
in the U.S.

•

First state to pass a Gay and Lesbian Student Rights Law protecting students
against discrimination in schools (1993).

•

First Safe Schools Program for Gay and Lesbian Students (1993).

•

First state to legalize marriage equality for same-sex couples (2003 Supreme
Judicial Court ruling; marriage legalized in May 2004).

•

First state to use Older Americans Act funding (Title III c) to support LGBT-focused
congregate meal programs (2004).

•

Sixteenth state to pass a gender identity nondiscrimination law (2011). Law
implemented as of July 1, 2012; excludes protections for public accommodations.

•

First state Executive Office of Elder Affairs to designate LGBT elders a population of
“greatest social need” under the Older Americans Act (2012).

•

First and only statewide LGBT Aging Commission (2014).

•

Massachusetts Board of Education endorses recommendations from the Safe
Schools Program of the Massachusetts Department of Elementary and Secondary
Education and the Massachusetts Commission on LGBTQ Youth calling for
the inclusion of LGBTQ individuals in school curricula, and the availability of ageappropriate materials on LGBTQ themes in libraries and student and faculty
resource centers (2015).

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LGBT AGING COMMISSION

APPENDICES

Appendix B: LGBT Older Adults’ Need to Access Mainstream Services
Lesbian, gay, bisexual and transgender (LGBT) elders are less likely to have children
than heterosexuals and more likely to be single and live alone, making them more
dependent on formal caregiving and elder services. Because most elder caregiving
in the U.S. is provided by children or partners/spouses, LGBT elders may be at even
greater need for senior services. However, many LGBT elders fear discriminatory or
inappropriate treatment in senior service settings and at the hands of home care aides.
A number of studies have found widespread fear among older lesbians and gay men
of being rejected because of their sexual orientation in senior care settings, by both
residents and staff. Many gay and lesbian elders fear rejection or neglect by healthcare
providers. This is often based on actual experiences of discrimination or culturally
inappropriate treatment toward themselves or friends. Gay and lesbian seniors are
particularly concerned about possible discriminatory treatment by personal care
aides. These fears are often based on past experiences of discrimination. Anti-gay
discrimination, or discrimination based on real or perceived sexual orientation, was once
widespread in both public sector and private sector employment. Many LGBT people
have also experienced family and social rejection. Transgender Americans experience
widespread discrimination and family rejection.
Discrimination and harassment was most intense for people growing up in the 1940s and
‘50s, who are now in their 60s or older. Homosexuality was viewed as a mental illness
until 1973. Half a century ago all 50 states outlawed homosexuality. Massachusetts’
colonial-era criminalization statute was not struck down until 2003. Most major religious
considered homosexuality a sin. . Opinion research indicates that older Americans are
more likely to hold anti-gay views than younger age cohorts. They are also more likely
to hold inaccurate beliefs about the casual transmission of HIV. This can increase older
LGBT people’s vulnerability to discriminatory treatment in mainstream senior settings. It
can also make LGBT elders think that they must go back into the closet, and hide their

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LGBT AGING COMMISSION

sexual orientation or gender identity, in order to access senior services. The lack of
training available for elder service providers in meeting the unique needs of LGBT and
HIV-positive older adults is an issue that requires immediate attention.
The lifetime experience of discrimination and social rejection may make LGBT elders
less likely to access mainstream elder services: a federal government survey in 2001
found that LGBT elders were only 20% as likely as heterosexual elders to access
services such as attending a senior center or congregate meal program, housing
assistance, food stamps, or other entitlements. Lower rates of accessing mainstream
senior services can exacerbate social isolation, which can contribute to depression
and poor treatment adherence. These factors, coupled with the lower rates of
parenting among LGBT elders noted above, may make LGBT eldersâ&#x20AC;&#x2122; ability to access
nondiscriminatory and affirming elder services especially important.
Excerpted and adapted from Cahill S. 2014. Community resources and government services for LGBT older adults
and their families. Orel N, Fruhauf C (eds.). The Lives of LGBT Older Adults: Understanding Challenges and
Resilience. Washington, DC: American Psychological Association, 141-170. Citations are included in original chapter.

59

LGBT AGING COMMISSION

APPENDICES

Appendix C: Resources on LGBT Aging
1. LGBT Aging in Massachusetts
•

The Health of LGBT persons in Massachusetts (MA Department of Public Health,
July 2009)

•

Meal Site Study Executive Summary Final (M’LANA Coalition, October 2012)

•

Meal Site Study Community Report Final (M’LANA Coalition, October 2012)

2. Needs Assessments
•

Out and Aging: The MetLife Study of Lesbian and Gay Baby Boomers (MetLife
Mature Market Institute, November 2006)

Appendix D: American Psychological Association Brief on Gender Dysphoria
GENDER DYSPHORIA
In the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), people whose gender at birth is contrary to the one they identify with will
be diagnosed with gender dysphoria. This diagnosis is a revision of DSM-IV’s criteria
for gender identity disorder and is intended to better characterize the experiences of
affected children, adolescents, and adults.
R E S P E C T I N G T H E PAT I E N T, E N S U R I N G A C C E S S T O C A R E
DSM not only determines how mental disorders are defined and diagnosed, it also
impacts how people see themselves and how we see each other. While diagnostic terms
facilitate clinical care and access to insurance coverage that supports mental health,
these terms can also have a stigmatizing effect.
DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and
feel themselves to be a different gender than their assigned gender. It replaces
the diagnostic name “gender identity disorder” with “gender dysphoria,” as well as
makes other important clarifications in the criteria. It is important to note that gender
nonconformity is not in itself a mental disorder. The critical element of gender dys¬phoria
is the presence of clinically significant distress associated with the condition.
CHARACTERISTICS OF THE CONDITION
For a person to be diagnosed with gender dysphoria, there must be a marked difference
between the individual’s expressed/experienced gender and the gender others would
assign him or her, and it must continue for at least six months. In children, the desire to
be of the other gender must be present and verbalized. This condition causes clinically
significant distress or impairment in social, occupational, or other important areas of
functioning.
Gender dysphoria is manifested in a variety of ways, including strong desires to

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LGBT AGING COMMISSION

be treated as the other gender or to be rid of one’s sex characteristics, or a strong
conviction that one has feelings and reac¬tions typical of the other gender.
The DSM-5 diagnosis adds a post-transition specifier for people who are living fulltime as the desired gender (with or without legal sanction of the gender change). This
ensures treatment access for indi¬viduals who continue to undergo hormone therapy,
related surgery, or psychotherapy or counseling to support their gender transition.
Gender dysphoria will have its own chapter in DSM-5 and will be separated from Sexual
Dysfunctions and Paraphilic Disorders. DSM-5 diagnosis adds a post-transition specifier
for people who are living full-time as the desired gender (with or without legal sanction
of the gender change). This ensures treatment access for individuals who continue to
undergo hormone therapy, related surgery, or psychotherapy or counseling to support
their gender transition.
Gender dysphoria will have its own chapter in DSM-5 and will be separated from Sexual
Dysfunctions and Paraphilic Disorders.
NEED FOR CHANGE
Persons experiencing gender dysphoria need a diagnostic term that protects their
access to care and won’t be used against them in social, occupational, or legal areas.
When it comes to access to care, many of the treatment options for this condition
include counsel¬ing, cross-sex hormones, gender reassignment surgery, and social
and legal transition to the desired gender. To get insurance coverage for the medical
treatments, individuals need a diagnosis. The Sexual and Gender Identity Disorders
Work Group was concerned that removing the condition as a psychiatric diagnosis—as
some had suggested—would jeopardize access to care.

Sex, Gender Identity and Gender Expression
This report intentionally uses non-gendered language both to promote
inclusivity and to reflect the non-binary nature of sex, gender, sexual
orientation, gender identity, and gender expression. Although in this
report the terms “lesbian”, “gay”, “bisexual,” and “transgender” are
used to describe minority sexual orientations, gender identities and
gender expressions we are cognizant that such language is limited. Our
understanding of sex, gender, gender identity, gender expression, and
sexual orientation is rapidly expanding and changing as is the lexicon used.
The use of “lesbian”, ”gay, and “bisexual” is intended to be inclusive of the
diversity of minority sexual orientations. Similarly the use of “transgender” is
intended to be inclusive of the range of minority gender identities and gender
expressions.
Some of our recommendations, such as the need for culturally competent
and effective training, apply to all minority sexual orientations, gender
identities, and gender expressions. Others may be differently applicable to
particular subgroups.
This statement is intended to explain and encourage the use of nongendered language and make explicit our intention to be inclusive of the
diversity of people of minority sex, sexual orientation, gender identity, and
gender expression notwithstanding the current limitations of language.
While some older adults who engage in same sex behavior or transcend the
gender binary use some other term to describe themselves we use “lesbian,
gay, bisexual and transgender (LGBT) to describe this population. LGBT
has emerged as the consensus term and the most widely used term by
community members, policy makers and service providers. This language
was also used in the legislation which created the Massachusetts LGBT
Aging Commission.